Fillable PALM BEACH COUNTY LOCAL BUSINESS TAX FEE EXEMPTION (Constitutional Tax Collector)

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PALM BEACH COUNTY LOCAL BUSINESS TAX FEE EXEMPTION (Constitutional Tax Collector)

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The PALM BEACH COUNTY LOCAL BUSINESS TAX FEE EXEMPTION (Constitutional Tax Collector) form is 2 pages long and contains:

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  • 9 check-boxes
  • 36 other fields

Country of origin: US
File type: PDF

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*Business Name/Organization/Entity:___________________________________________________________________
*Business Address:__________________________________________________________________________________
*City:________________________________________State:______________________ZIP Code:__________________
Mailing Address
(if different from above):______________________________________________________________________
City:_________________________________________State:______________________ZIP Code:__________________
Local Business Tax Receipt # (if applicable):______________________________________________________________
*Federal Employer Identifi cation Number (FEIN):____________________or Social Security Number:____________________
*Contact Person:___________________________________________Title/Relationship:______________________________
*Phone:_____________________________________Alternate Phone:_______________________________________
*Email:____________________________________________________________________________________________
______________________________________________ _________________________________________________
______________________________________________ _________________________________________________
Print Name
Signature
Title/Relationship
Date
www.pbctax.com @TAXPBC
PALM BEACH COUNTY LOCAL BUSINESS TAX
FEE EXEMPTION APPLICATION
PBCTC Form 49 Rev.6/29/2018
I hereby attest that I am authorized to sign on behalf of the applicant / organization or entity described above. I further attest that if
granted, this exemption will only be used in the manner authorized under the provisions of Chapter 205 of the Florida Statutes.
Under penalties of perjury, I declare that I have read the foregoing application and that the facts stated and attached herein are true.
Reason for Filing (check one):
Honorably discharged veteran
Spouse of honorably discharged veteran
Un-remarried surviving spouse of honorably discharged veteran
Spouse of certain active duty military service member who relocated to
the county pursuant to a permanent change of station order
Disabled person (please have reverse side completed by a physician)
Widow with minor dependent(s)
Person 65 years of age or older
Low income individuals receiving public assistance (re-evaluated yearly)
Low income individuals with a household income less than 130 percent of the
federal poverty level based on the current year’s federal poverty guidelines
Mail Exemption
Application to:
Tax Collect
or,
Palm Beach County
P.O. Box 3353
West Palm Beach, FL
33402-3345
*Starred Fields are Required
All information is required to process your exemption application. First time applicants are required to complete an
Application for P
alm Beach County Local Business Tax Receipt Form 65 in addition to this form.
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signature
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STATE OF FLORIDA COUNTY OF __________________________________________________________________________
I, __________________________________________, hereby certify that I am a licensed practicing physician, located at
______________________________________________________________, Florida, and I am personally acquainted with
___________________________________________________ who is an applicant for the exemption from payment of
business tax under the provisions of Chapter 205 of the Florida Statutes, and that on
(MM/DD/YYYY)________________
I have thoroughly examined the said applicant and found him/her to be physically disabled. The nature and extent of the
applicant’s disability are as follows:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
PHYSICIAN’S CERTIFICATE FOR DISABLED PERSONS
Physician’s Signature
____________________________________________________
Print Physician’s Name
____________________________________________________
Phone Number
___________________________________
Date
___________________________________
Address
___________________________________
___________________________________
___________________________________
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PALM BEACH COUNTY LOCAL BUSINESS TAX FEE EXEMPTION (Constitutional Tax Collector)

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Completed 11 April 2021

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